Is salary in CL really as bad as everyone suggests?

[chajjohnson]

I'm an MS4 going into psych, and I'm thinking about consults being a significant part of my career, at least half. However I'm a little worried about the poor reputation this field's salary has among the community. Even the consult docs I worked with were constantly complaining about the salary. I know it's hard to estimate, but can anyone guess what the salary would be for someone doing full time consults (e.g M-F day coverage)? Do all consult docs need to supplement with something more lucrative like 1-3 outpatient days per week? None of the consult docs I worked with did full time, they all did 1-3 days per week. Honestly I felt like that practice model led to fragmented knowledge and care among the census with a new doc picking up the service almost every day

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[Merely]

what would you consider "bad"?

<250k/yr

 

[splik]

most psychiatrists make <250k/yr. while is certainly very possible to make more than that in psychiatry depending on your flexibility with work, setting, and location, psychiatry is still one of the lowest paying fields and the average psychiatrist is not making 250k.

you have to bear in mind that most hospitals don't have the volume to have full time C/L positions as it is. usually doing consults is considered an additional part of the job (which might be inpatient or outpatients). at larger hospitals the volume would be much greater but many of those hospitals are also academic institutions or academically affiliated and thus they do pay less. of course you might be able to get a cushy job doing C/L and kaiser and get paid very well, but most of the time you would end up working some outpatient as well.

I do C/L psychiatry at a large academic institution. The pay as you can imagine is not high flying but it is fair. We see fewer patients doing C/L and spend longer on coordination of care etc, which means we don't generate as much revenue. RVU models are not a good way of getting remunerated as a C/L psychiatrist. We are cost saving for hospitals by getting patients out and reducing readmissions etc and more creative funding streams need to be negotiated for C/L psychiatrists.

Some outpatient specialized evaluation work can pay decently (e.g. bariatric surgery evals, gender reassignment surgery evals, transplant candidate and live donor evals).

I work pretty hard and supplement my income by various other activities (i.e. expert witness work, consulting etc)

I don't want to discount financial aspects of things. They are obviously an important fact. But if you do what you love, and don't let yourself get exploited, then you can't go wrong. I could work less and make the same or more doing something else but I love what I do, the variety of different activities I do, and feel very fortunate to have the opportunity to do the work that I do.

 

[chajjohnson]

From what I've heard, a standard full-time outpatient psych job will pay at least 250K in most systems. Depending on how busy the consult service is and the hours required I would say <250K is poor. I understand how RVUs work, but in all fairness C/L is a psych subspecialty that requires extra training and in my mind it would be ideal to receive the same amount of money as a psychiatrist with no extra training doing outpatient. In addition as Splik mentioned a C/L service is basically a discharge service that can save the hospital tons of money. Would it be possible to reach 250K doing 1/2 time consults, 1/2 inpt or outpatient?

 

[SourceOfDenial]

I understand how RVUs work, but in all fairness C/L is a psych subspecialty that requires extra training and in my mind it would be ideal to receive the same amount of money as a psychiatrist with no extra training doing outpatient.

C/L doesn't require extra training.

Services that reduce cost don't get compensated well. You can't bill an insurance company for saving money. Not yet at least.

You do something because you like it. There are lots of ways to make extra money.

 

[nexus73]

From what I've heard, a standard full-time outpatient psych job will pay at least 250K in most systems. Depending on how busy the consult service is and the hours required I would say <250K is poor. I understand how RVUs work, but in all fairness C/L is a psych subspecialty that requires extra training and in my mind it would be ideal to receive the same amount of money as a psychiatrist with no extra training doing outpatient. In addition as Splik mentioned a C/L service is basically a discharge service that can save the hospital tons of money. Would it be possible to reach 250K doing 1/2 time consults, 1/2 inpt or outpatient?

Yes, but, the balance will probably be closer to 1/4 consults, 3/4 inpatient or outpatient...at least in my experience at community hospitals.

 

[splik]

From what I've heard, a standard full-time outpatient psych job will pay at least 250K in most systems.

You can certainly find many jobs that do pay 250k. Most of my friends are not making 250k and that is well above the national median income for a psychiatrist. I estimate making more than that this year but I have additional sources of revenue beyond my C/L job.

at any rate, it is really not helpful for you to be thinking about these things now. When I was applying for residency, people were talking about the death of C/L but since that time it has been one of the major areas of growth in the fields. many hospitals that didnt provide any psychiatric consultation now do. With different models of funding in existence and more data supporting the value provided by C/L psychiatrists, and the growing mental health needs of medically ill patients this has significantly increased the presence of C/L psychiatry and remuneration. in an RVU based model C/L psychiatrists are big losers. We have no idea what will happen by the time you graduate. Right now, outpatient c/l services have been massively expanding. At some point the psychiatry compensation bubble is going to burst and income will fall. we don't know when that is going to happen, but happen it will. At any rate, who knows what you will decide to do after you've done your psychiatric training. You may decide there are other aspects of the field that you enjoy more.

 

[FlowRate]

At some point the psychiatry compensation bubble is going to burst and income will fall.

Why do you think there's a bubble specific to psychiatry?

 

[splik]

Why do you think there's a bubble specific to psychiatry?

Because psychiatrists' income has risen at an unsustainable rate, far outpacing changes seen in primary care and during a time when reimbursement in other specialties (including neurology) were cut. There is a natural ebb and flow in physician salaries over time but the last time psychiatrists' reimbursement was riding high like this was in the 1970s, after which point it precipitously dropped when insurance companies got fed up of not being able to review our records, endless hospitalizations for therapeutic regression, and endless psychoanalysis which at best did little and at worst damaged the patients. The increase in psychiatrists' compensation has primarily been driven by 1) lawsuits in managed care (e.g. Kaiser), corrections, and the VA; 2) changes to mental health CPT codes (transition to E/M codes and the development of "psychotherapy add-on codes"); and 3) increased visibility of so-called "behavioral health" particularly in the medically ill population. This has been coupled with a "demand" created by the ACA (insuring large numbers of people who previously didn't seek care) and the pharmaceutical industry (e.g. convincing people they have adult ADHD).

All of the above mean we will at the very least see a plateau (i'm already seeing this) which ultimately equal a fall in income and means that psychiatry is especially vulnerable to things like local budgetary constraints (as psychiatrists are among the highest paid employees of municipal and state governments), CPT code changes, healthcare reform, and the integration of "behavioral health" with the rest of medicine. All of this imho is more significant than psych NPs, rxPs or other bogeymen people get up in arms about.

now you can argue that cash practice is the answer to all this, but I am specifically focusing on employed positions here, and cash practice while much more viable in psych than any other field is still at the mercy of other forces and is not going to be an option for those with the more serious mental health needs.

 

[slappy]

most psychiatrists make <250k/yr. while is certainly very possible to make more than that in psychiatry depending on your flexibility with work, setting, and location, psychiatry is still one of the lowest paying fields and the average psychiatrist is not making 250k.

you have to bear in mind that most hospitals don't have the volume to have full time C/L positions as it is. usually doing consults is considered an additional part of the job (which might be inpatient or outpatients). at larger hospitals the volume would be much greater but many of those hospitals are also academic institutions or academically affiliated and thus they do pay less. of course you might be able to get a cushy job doing C/L and kaiser and get paid very well, but most of the time you would end up working some outpatient as well.

I do C/L psychiatry at a large academic institution. The pay as you can imagine is not high flying but it is fair. We see fewer patients doing C/L and spend longer on coordination of care etc, which means we don't generate as much revenue. RVU models are not a good way of getting remunerated as a C/L psychiatrist. We are cost saving for hospitals by getting patients out and reducing readmissions etc and more creative funding streams need to be negotiated for C/L psychiatrists.

Some outpatient specialized evaluation work can pay decently (e.g. bariatric surgery evals, gender reassignment surgery evals, transplant candidate and live donor evals).

I work pretty hard and supplement my income by various other activities (i.e. expert witness work, consulting etc)

I don't want to discount financial aspects of things. They are obviously an important fact. But if you do what you love, and don't let yourself get exploited, then you can't go wrong. I could work less and make the same or more doing something else but I love what I do, the variety of different activities I do, and feel very fortunate to have the opportunity to do the work that I do.

Not true. Academics isn't the whole world. MGMA 50th percentile salary even for early career psychiatrists is well above that mark, and the average psychiatrist is very much making that much (more, in fact).

 

[slappy]

Because psychiatrists' income has risen at an unsustainable rate, far outpacing changes seen in primary care and during a time when reimbursement in other specialties (including neurology) were cut. There is a natural ebb and flow in physician salaries over time but the last time psychiatrists' reimbursement was riding high like this was in the 1970s, after which point it precipitously dropped when insurance companies got fed up of not being able to review our records, endless hospitalizations for therapeutic regression, and endless psychoanalysis which at best did little and at worst damaged the patients. The increase in psychiatrists' compensation has primarily been driven by 1) lawsuits in managed care (e.g. Kaiser), corrections, and the VA; 2) changes to mental health CPT codes (transition to E/M codes and the development of "psychotherapy add-on codes"); and 3) increased visibility of so-called "behavioral health" particularly in the medically ill population. This has been coupled with a "demand" created by the ACA (insuring large numbers of people who previously didn't seek care) and the pharmaceutical industry (e.g. convincing people they have adult ADHD).

All of the above mean we will at the very least see a plateau (i'm already seeing this) which ultimately equal a fall in income and means that psychiatry is especially vulnerable to things like local budgetary constraints (as psychiatrists are among the highest paid employees of municipal and state governments), CPT code changes, healthcare reform, and the integration of "behavioral health" with the rest of medicine. All of this imho is more significant than psych NPs, rxPs or other bogeymen people get up in arms about.

now you can argue that cash practice is the answer to all this, but I am specifically focusing on employed positions here, and cash practice while much more viable in psych than any other field is still at the mercy of other forces and is not going to be an option for those with the more serious mental health needs.

Bubbles don't have plateaus. But then I don't see a plateau, nor do I see any characteristics of a bubble here. Have you actually looked at historical psychiatrists' salaries in the US? The rest of your thesis isn't sound from a financial perspective either, but I'm curious about the reimbursement rates in the 70s. Where did you get your data for that?

 

[FlowRate]

Interesting/relevant white paper w/r/t psychiatrist salary. Obviously somewhat biased figures -- like MGMA -- in that it's tied to recruiting, but they seem to think there's more to psychiatrist pay increases than just the coding changes / visibility (short term demand.) https://www.merritthawkins.com/uplo...hysician_Incentive_Review_Merritt_Hawkins.pdf

 

[michaelrack]

mid 200's may be what the average psych job pays, but how many nonacademic psychiatrists out there just work one job?? All of the male psychiatrists I know, event the "full-time employed" ones, have more than 1 position.

 

[slappy]

Interesting/relevant white paper w/r/t psychiatrist salary. Obviously somewhat biased figures -- like MGMA -- in that it's tied to recruiting, but they seem to think there's more to psychiatrist pay increases than just the coding changes / visibility (short term demand.) https://www.merritthawkins.com/uplo...hysician_Incentive_Review_Merritt_Hawkins.pdf

Of course in a free market, it's the demand that dictates price, so nothing surprising there. I don't see that changing anytime soon, despite all the fears of midlevel encroachment. So all this concern about the compensation increase being a bubble is overblown speculation/fear without a basis in reality.

Things could change if all of the older psychiatrists decide to retire at the same time, but that doesn't really happen though, does it? We tend to continue working for several years past the "normal age of retirement" as we seem to actually enjoy what we do - we talk to patients. What better way to combat boredom in older age than to spend it passing on experience/wisdom/knowledge/help to people who we think would benefit from them! That it's one of the least physically intensive specialties doesn't hurt either.

As a side note, I don't see why MGMA salaries are any more biased than the other reports out there. Sure they have a bit of a selection bias as the primary respondents are from mid-sized groups, but their results correlate very well year after year with AMGA survey results that don't have that bias. MGMA and AMGA are the two biggest surveys making them more reliable than most.

 

[Armadillos]

Healthcare economics are always mysterious to me, so forgive me if this is obvious.

How are we saving hospitals money when we do inpatient C/L?

Seems like a decent percent of consults end up with us saying please don’t discharge that suicidal or floridly psychotic patient and then they sit with a 1:1 sitter on some super pissed off medical service for days until they can get inpatient psychiatric care somewhere. I can’t imagine the hospital is making any money from that.

 

[slappy]

Healthcare economics are always mysterious to me, so forgive me if this is obvious.

How are we saving hospitals money when we do inpatient C/L?

Seems like a decent percent of consults end up with us saying please don’t discharge that suicidal or floridly psychotic patient and then they sit with a 1:1 sitter on some super pissed off medical service for days until they can get inpatient psychiatric care somewhere. I can’t imagine the hospital is making any money from that.

E/M coders are often able to get the insurers to pay at least partially for those days so the cost there is mitigated. Inpatient C/L primarily generates income through an overall reduction in length of hospital stay by facilitating discharge both at the patient-level (discharge anxiety, attenuating other psychiatric symptoms improving overall care delivery, etc) and at the systems-level (finding appropriate dispo for high utilizers like substance users so their illness is treated effectively, etc). Then there's the other, difficult-to-measure benefits of risk mitigation (suicidal/homicidal patients), boosting staff morale (fewer behavioral outbursts in delirium and dementia), etc. NHS found a cost-benefit ratio of 1:3 just using the shorter discharge measure.

 

[wolfvgang22]

Quality conversation. I don't think we'll see a big drop in salary anytime soon, especially with the media decrying a lack of mental health care every time there is a shooting and as long as patriotic public opinion is driving improved mental health care in the VA. Just my opinion.

Also, Psychiatrist pay in the VA is capped by law at $264k since 2014, so that actually isn't driving up salaries for psychiatrists. Congress talks the talk of helping more veterans but doesn't fully back it up. VA pay scale for Psychiatrists may unintentionally set a benchmark for some employers, I don't know. I do know psychiatrists avoid working for the VA due to perceived low pay and high bureaucracy and paperwork burden.

 

[Blitz2006]

Quality conversation. I don't think we'll see a big drop in salary anytime soon, especially with the media decrying a lack of mental health care every time there is a shooting and as long as patriotic public opinion is driving improved mental health care in the VA. Just my opinion.

Also, Psychiatrist pay in the VA is capped by law at $264k since 2014, so that actually isn't driving up salaries for psychiatrists. Congress talks the talk of helping more veterans but doesn't fully back it up. VA pay scale for Psychiatrists may unintentionally set a benchmark for some employers, I don't know. I do know psychiatrists avoid working for the VA due to perceived low pay and high bureaucracy and paperwork burden.

So follow-up question, if the salary is capped at 264K, what is the average VA salary? Is that also extremely variable geographically, or does the VA in NYC pay roughly same as VA in Idaho?

 

[Blitz2006]

FYI, outside of Northeast, I haven't seen a job offer less than 250k. In fact, the majority of job offers in most of the country is 250-300k, and I would say the median is probably 270k (outside of Northeast). And if you are happy with small town Midwest, 350k is very doable.

I would say in the North East, the range is 225k-250k (apart from Boston/NYC, which the range is 160-200k).

 

[splik]

FYI, outside of Northeast, I haven't seen a job offer less than 250k. In fact, the majority of job offers in most of the country is 250-300k, and I would say the median is probably 270k (outside of Northeast). And if you are happy with small town Midwest, 350k is very doable.

well you do realize that only jobs that pay higher tend to tell you how much they pay which skews things. also the midwest is one of the lower paying parts of the country nowadays so im not sure where this idea you'll be making 350k there in a typical job comes from. you won't.

The thread has sort of job off tangent - which is what C/L jobs pay vs. the rest. the pay is potentially lower, but not necessarily. I have a friend who makes a decent amount doing C/L in a less desireable part of the country. it is unusual for people to work full time in C/L anyway and can easily be combined with outpatient C/L (i.e. integrated care), outpatient private practice, ER work, alternating with inpatient psychiatry etc. and in some settings (certain academic medical centers, county hospitals, VA, managed care) you can expect the make the same as colleagues doing other work in that institution. the issue is fee-for-service.

 

[FlowRate]

As a side note, I don't see why MGMA salaries are any more biased than the other reports out there. Sure they have a bit of a selection bias as the primary respondents are from mid-sized groups, but their results correlate very well year after year with AMGA survey results that don't have that bias. MGMA and AMGA are the two biggest surveys making them more reliable than most.

I don't know enough about AMGA to comment on them, but MGMA and Merrit Hawkins--and any other data pulled from recruiters / recruiting firms (or, heck, listings that advertise salary)--are inherently going to be skewed toward higher salary. The point is that they are hard-to-fill jobs.

 

[splik]

Healthcare economics are always mysterious to me, so forgive me if this is obvious.

How are we saving hospitals money when we do inpatient C/L?

Seems like a decent percent of consults end up with us saying please don’t discharge that suicidal or floridly psychotic patient and then they sit with a 1:1 sitter on some super pissed off medical service for days until they can get inpatient psychiatric care somewhere. I can’t imagine the hospital is making any money from that.

there is a difference between making money and saving money. if your suicidal patient jumps from the rooftop of the hospital (as happened at several places ive worked) that is an enormous payout. they are quite happy to have the damn sitter watch the patient even though the nurses bitterly complain about it. there is nothing like a patient suicide or delirious patient tumbling to their death from the stairwell to focus the minds of the administrators and demand a C/L service with a director.

other than that managing delirium and behavioral disturbances often contribute to prolonged hospitalization for patients and an effective C/L service helps with this. many patients end up in the hospital with complications of non-adherence and an effective C/L service helps with this. Patients with recurrent presentations of DKA usually have borderline personality disorder and the C/L service can help with this particular manifestation of their personality disorder. untreated mood disorders often contribute to morbidity from medical conditions, missed appointments, neglect, and non-adherence, and a functioning C/L service can help with this. for other personality disordered and substance abusing patients an effective C/L team can come up with a behavioral management plan. for patients with factitious disorders, the C/L team can help identify these patients and come up with a management plan to avoid iatrogenic harm and unnecessary investigations. effective integration of mental health care with follow up helps reduce 30-day readmission rates (for which hospitals lose money) etc etc. finally, patients with psychiatric disorders and dementia tend to spend the longest time on medicine wards blocking beds and to some extent (obviously lack of dispo options to SNFs and long-term care facilities can be obstacles but often behavioral disturbance limits dispo) psychiatry can help manage these patients so they can be discharged, and patients who need more active intervention (and thus generate more revenue for the hospitals) can fill those beds instead.

another service that doesn't generate $$$ for hospitals is palliative medicine. but it is also one of the services with the highest satisfaction scores from patients and family and enormously helpful in other ways, which is why more hospitals pay for this service.

 

[NickNaylor]

At our academic center, newly graduated C/L fellows are being offered ~$250k for 40 hours/week on the C/L service.

 

[chajjohnson]

At our academic center, newly graduated C/L fellows are being offered ~$250k for 40 hours/week on the C/L service.

That sounds real nice. Do you know if that is only for fellowship trained CL docs? Are they doing other administrative duties like running a fellowship?

 

[SoCalTime]

650K. That's achievable. And I specialize. And I make it home in time to pick up my child from school almost every day (3pm). I realize I'm the extreme exception. You have to be in high demand, be very savvy, in the right place at the right time, with very good networking and negotiating skills. I'm not in C/L, but since this thread took a turn into what psychiatrists can make, I wanted to give some perspective.

 

[SoCalTime]

Mind if I ask what you specialize in and what it takes to make that kind of money in psychiatry?

My best advice is to become a unicorn. Pursue experience and training that sets you apart from the rest, and get your name out there. Nobody ever taught me about the non-traditional paths, I discovered them for myself. Think beyond being an employee. I reached powerful people in high places, gods of the heavens. As for the type of unicorn to become, that's for you to decide.

 

[TexasPhysician]

My best advice is to become a unicorn. I reached powerful people in high places, gods of the heavens. As for the type of unicorn to become.....

Is this SDN or the Fantasy Games Forum? 🙂

 

[dl2dp2]

Is this SDN or the Fantasy Games Forum? 🙂

This is getting out of hand. How did every other thread turn into how can I be a shrink and clear half a mil thread??? LOL

And just to be clear, you don't need to be a unicorn and know "gods of the heavens" and clear half a mil. I suspect, for example, TexasPhysician and Michaelrack both get somewhere close to that but they stay below the radar...as they should be...

 

[WisNeuro]

Is this SDN or the Fantasy Games Forum? 🙂

Oh oh oh, I want to be a Half-elf paladin!

 

[wolfvgang22]

My half- elf paladins always get pwned.
Anyways, I agree these salary topics have been done enough. I think I'm going to quit commenting on salary threads myself. Students should do what I did when I first came here and use the search function and then ask questions not otherwise answered.

 

[NickNaylor]

That sounds real nice. Do you know if that is only for fellowship trained CL docs? Are they doing other administrative duties like running a fellowship?

Strictly clinical position as far as I know, but medical students and residents rotate on to the service, so some education stuff would be a part of the work. Built into that compensation are bonuses for being fellowship-trained, so the salary wouldn’t be the same for a generalist doing C/L work.

 

[FlowRate]

This is getting out of hand. How did every other thread turn into how can I be a shrink and clear half a mil thread??? LOL

And just to be clear, you don't need to be a unicorn and know "gods of the heavens" and clear half a mil. I suspect, for example, TexasPhysician and Michaelrack both get somewhere close to that but they stay below the radar...as they should be...

And being a unicorn doesn't have to be so grandiose. I met a guy who has a half-time high-ranking academic position who spends maybe 500-1000 hours a year doing family therapy with anorexics at $500/hr. It's not like he created a new field or had to meet socialites to develop this practice. In other words, it's possible to become a "unicorn" by the combination of otherwise uncommon (but not unique or inconceivable) traits e.g. academic credential, high SES patient population, specific focus in fellowship-gated field.

Maybe SoCal does performance coaching or other concierge stuff for people with recognizable names. Someone who recently graduated from my residency program chose to focus on performance coaching/therapy. It's not impossible to identify these interests and gain relevant experience during residency.

 

[surfguy84]

And being a unicorn doesn't have to be so grandiose. I met a guy who has a half-time high-ranking academic position who spends maybe 500-1000 hours a year doing family therapy with anorexics at $500/hr. It's not like he created a new field or had to meet socialites to develop this practice. In other words, it's possible to become a "unicorn" by the combination of otherwise uncommon (but not unique or inconceivable) traits e.g. academic credential, high SES patient population, specific focus in fellowship-gated field.

Maybe SoCal does performance coaching or other concierge stuff for people with recognizable names. Someone who recently graduated from my residency program chose to focus on performance coaching/therapy. It's not impossible to identify these interests and gain relevant experience during residency.

How does one get into one of those niches; i.e. performance therapy? I'm assuming most programs don't have a ton of exposure to this aspect of pscyhiatry.

 

[FlowRate]

How does one get into one of those niches; i.e. performance therapy? I'm assuming most programs don't have a ton of exposure to this aspect of pscyhiatry.

It helps to be in a large metro / academic center with a lot of loosely affiliated folk who stick around in the area--that way you can potentially get supervision from people with a similar niche. Part of it is just asking for patients who fit a specific demographic to take on your outpatient panel in 3rd/4th year.

 

[slappy]

Strictly clinical position as far as I know, but medical students and residents rotate on to the service, so some education stuff would be a part of the work. Built into that compensation are bonuses for being fellowship-trained, so the salary wouldn’t be the same for a generalist doing C/L work.

Good news is quite often these academic built-in "fellowship-trained" bonuses are pretty flexible and aren't limited to C/L fellowships.

 

[calvnandhobbs68]

650K. That's achievable. And I specialize. And I make it home in time to pick up my child from school almost every day (3pm). I realize I'm the extreme exception. You have to be in high demand, be very savvy, in the right place at the right time, with very good networking and negotiating skills. I'm not in C/L, but since this thread took a turn into what psychiatrists can make, I wanted to give some perspective.

Sounds legit.

 

[NickNaylor]

Good news is quite often these academic built-in "fellowship-trained" bonuses are pretty flexible and aren't limited to C/L fellowships.

Yeah, this is the case here, too - there’s just a general bonus for every fellowship board certification you hold if you join the faculty, irrespective of whether or not the fellowship has any actual relevance to the work that you’re doing.

 

[dl2dp2]

And being a unicorn doesn't have to be so grandiose. I met a guy who has a half-time high-ranking academic position who spends maybe 500-1000 hours a year doing family therapy with anorexics at $500/hr. It's not like he created a new field or had to meet socialites to develop this practice. In other words, it's possible to become a "unicorn" by the combination of otherwise uncommon (but not unique or inconceivable) traits e.g. academic credential, high SES patient population, specific focus in fellowship-gated field.

Maybe SoCal does performance coaching or other concierge stuff for people with recognizable names. Someone who recently graduated from my residency program chose to focus on performance coaching/therapy. It's not impossible to identify these interests and gain relevant experience during residency.

How does one get into one of those niches; i.e. performance therapy? I'm assuming most programs don't have a ton of exposure to this aspect of pscyhiatry.

You are missing my point, and I think your point is misleading to trainees. Frankly I don't think this is how typically someone makes 400-500k in psych. I have no doubt of the veracity of your story, but I think many many many more psychiatrists in the community make 500k than the ones doing this kind of "unicorn" practice.

It's really not that complex: you want to bill approximately $400+ per hour and work around 30 clinical hours. Depending on the payer mix and patient population, you might burn out quickly by seeing mostly insurance patients, or not if you see cash for therapy. Things fill up quickly or slowly depending on your niche (i.e. sleep, addiction, child etc.). 99214+90833 ~ $170, bill 2-3 per hour and you are done. The best value in psych is still outpatient subspecialty psychopharm.

High end cash is not the be all end all in making money. For example, in big markets, there are some insurance taking MDs who have a panel of NP helpers, and these group owners probably make more than your garden variety Wilshire Blvd UCLA trained high end cash. The advantage of high end cash is low overhead, low hassle, and high per hour yield. At the end of the day, you make more money when you have people who work for you even when you are not working. High end cash is the opposite of that philosophy -- it focuses on the uniqueness, "boutique quality", "high quality" of the patient-doctor relationship. But even people without a name brand residency or "unicorn" skills can build a high volume practice and hire NP helpers if they are business savvy and/or willing to learn, and as time go on they can make really good money.

 

[FlowRate]

You are missing my point, and I think your point is misleading to trainees. Frankly I don't think this is how typically someone makes 400-500k in psych. I have no doubt of the veracity of your story, but I think many many many more psychiatrists in the community make 500k than the ones doing this kind of "unicorn" practice.

It's really not that complex: you want to bill approximately $400+ per hour and work around 30 clinical hours. Depending on the payer mix and patient population, you might burn out quickly by seeing mostly insurance patients, or not if you see cash for therapy. Things fill up quickly or slowly depending on your niche (i.e. sleep, addiction, child etc.). 99214+90833 ~ $170, bill 2-3 per hour and you are done. The best value in psych is still outpatient subspecialty psychopharm.

High end cash is not the be all end all in making money. For example, in big markets, there are some insurance taking MDs who have a panel of NP helpers, and these group owners probably make more than your garden variety Wilshire Blvd UCLA trained high end cash. The advantage of high end cash is low overhead, low hassle, and high per hour yield. At the end of the day, you make more money when you have people who work for you even when you are not working. High end cash is the opposite of that philosophy -- it focuses on the uniqueness, "boutique quality", "high quality" of the patient-doctor relationship. But even people without a name brand residency or "unicorn" skills can build a high volume practice and hire NP helpers if they are business savvy and/or willing to learn, and as time go on they can make really good money.

Oh I hoped the "And.." would come across as "in addition." That is, in addition to playing the volume/payer/business owner game, it's not as difficult to do niche as SoCal implied.

 

[SoCalTime]

No cash practice here. Was. Not anymore. I do like the festive speculation though. Unicorn practice... love it. Which becomes a bloody time suck. I don't sit in an office and wait for capitalists to come riding in. Performance therapy? No, no, god no.

 

[clausewitz2]

No cash practice here. Was. Not anymore. I do like the festive speculation though. Unicorn practice... love it. Which becomes a bloody time suck. I don't sit in an office and wait for capitalists to come riding in. Performance therapy? No, no, god no.

I'm sure being mysterious on an anonymous internet forum must feel good, but I would point out that it is not actually that difficult or impressive.